General Anesthesia with Tulip® Supraglottic Airway in a Term Pregnant Patient with Active Herpes Zoster: A Case Report

Abstract

Herpes zoster, a reactivation of the varicella-zoster virus (VZV), is uncommon during pregnancy but poses significant maternal and fetal risks, necessitating tailored anesthetic management. When neuraxial anesthesia is contraindicated due to lesions located near the insertion site, general anesthesia becomes a reasonable alternative. However, airway management is of paramount importance due to the risk of varicella pneumonia.
This case report presents a 39-week pregnant patient with active herpes zoster lesions over the spinal access site who underwent cesarean section under general anesthesia. Airway management was achieved with the Tulip® GT#3 supraglottic airway device, providing a secure and effective alternative to endotracheal intubation. The device was successfully inserted on the first attempt, providing effective ventilation. Aspiration risk was minimized through gastric decompression with an orogastric tube.
The postoperative course was uneventful for both mother and newborn. To the best of our knowledge, this is the first reported use of the Tulip Airway in an obstetric patient, highlighting its potential as a safe and effective alternative in appropriately selected cases.

Keywords

• Cesarean
• Herpes zoster
• Pregnancy
• Supraglottic airway
• Tulip airway

References

1. Lamont RF, Sobel JD, Carrington D, Mazaki-Tovi S, Kusanovic JP, Vaisbuch E, et al. Varicella-zoster virus (chickenpox) infection in pregnancy. BJOG. 2011;118(10):1155-62. doi:10.1111/j.1471-0528.2011.02983.x.
2. Datta S. Anesthetic and Obstetric Management of High-Risk Pregnancy. 2nd ed. Springer Science & Business Media; 2006.
3. Ray BR, Singhal D, Kumar A, Borle A, Baidya D. Anesthesia for cesarean section in a parturient with acute varicella: Is general anesthesia better than neuraxial anesthesia? J Obstet Anaesth Crit Care. 2012;2(2):105. doi:10.4103/2249-4472.104737.
4. Sanganee U, Jansen K, Lucas N, Van de Velde M. The role of supraglottic airway devices for caesarean section under general anaesthesia. A scoping literature review with a proposed algorithm for the appropriate use of supraglottic airway devices for caesarean sections. Eur J Anaesthesiol. 2024;41(9):668-76. doi: 10.1097/EJA.0000000000002024.
5. Royal College of Obstetricians and Gynaecologists. Chickenpox in pregnancy. Green-top Guideline No. 13. London: RCOG; 2015.
6. Janardhan AL, Gupta N, Prakash S, Gogna RL. Anesthetic management of a parturient with varicella presenting for cesarean delivery. Int J Obstet Anesth. 2016;28:92-4. doi:10.1016/j.ijoa.2016.06.002.
7. Kaur S, Shekhawat S. Anaesthetic management of a patient with varicella undergoing emergency caesarean section. Internet J Anesthesiol. 2012;30(2). doi:10.5580/2a5d.
8. Wolff M, Schünemann S. Acyclovir treatment prevents varicella-zoster virus replication in PBMC during viremia. New Microbiol. 1999;22(4):309-14.

9. Martin DP, Bergman BD, Berger IH. Epidural blood patch and acute varicella. Anesth Analg. 2004;99(6):1760-2. doi:10.1213/01.ANE.0000136473.18712.4B.
10. Brown NW, Parsons APR, Kam PCA. Anaesthetic considerations in a parturient with varicella presenting for Caesarean section. Anaesthesia. 2003;58(11):1092-5. doi:10.1046/j.1365-2044.2003.03442.x.
11. Harger JH, Ernest JM, Thurnau GR, Moawad A, Momirova V, Landon MB, et al. Risk factors and outcome of varicella-zoster virus pneumonia in pregnant women. J Infect Dis. 2002;185(4):422-7. doi:10.1086/338832.
12. Dave N, Sasane S, Iyer H. Caesarean section in a patient with varicella: anaesthesia considerations and clinical relevance. Indian J Anaesth. 2007;51(2):140.
13. Metodiev Y, Mushambi M. Supraglottic airway devices for Caesarean delivery under general anaesthesia: for all, for none, or for some? Br J Anaesth. 2020;125(1):e7-e11. doi:10.1016/j.bja.2020.02.012.
14. Shaikh A, Robinson PN, Hasan M. The Tulip GT® airway versus the facemask and Guedel airway: a randomised, controlled, cross-over study by Basic Life Support-trained airway providers in anaesthetised patients. Anaesthesia. 2016;71(3):315-9. doi:10.1111/anae.13328.
15. Robinson PN, Shaikh A, Sabir NM, Vaughan DJA, Kynoch M, Hasan M. A pilot study to examine the effect of the Tulip® oropharyngeal airway on ventilation immediately after mask ventilation following the induction of anaesthesia. Anaesthesia. 2014;69(7):707-11. doi:10.1111/anae.12662.
16. Imashuku Y, Kitagawa H, Mizuno T. Usefulness of Tulip Airway in edentulous elderly patients. Anesth Prog. 2022;69(3):9-12. doi:10.2344/anpr-69-01-01.
17. Harrison S, Robinson NP, Shaikh A, Yentis SM. Manikin evaluation of the Tulip®, a new supraglottic airway. Anaesthesia. 2009;64(7):807-7. doi:10.1111/j.1365-2044.2009.05966_20.x.